Guidelines: EOLC Symptom Control for Patients with Normal Renal Function (in Wandsworth)

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Marybeth Johnston
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1 Guidelines: EOLC Symptom Control for Patients with Normal Renal Function (in Wandsworth) Policy Number : DC020 Issue Date: October 2014 Review date: October 2016 Policy Owner: Head Community Services Monitor: Clinical Risk Group Summary This guidance offers the best choice of injectable medications and doses for symptom control at the end of life. Optimising the patient s medications contributes towards a care plan that is individualised to their needs at the end of life. Trinity Hospice: Adapted with permission from the Guys & St Thomas NHS Foundation Trust clinical guideline - End of life symptom control guidelines for adult inpatients with renal failure (egfr < 30 ml/ min) EoL symptom control guidelines Pain v1 April14 rev April 15 Page 1 of 10

2 Regular monitoring by Clinical Risk Group Evidence includes: Clinical Incidents Staff feedback. Audits of practice. Changes in legal and best practice guidance Monitoring Policy Effectiveness Author: Dr Sam Lund, Dr Sarah Cox, Dr Stephen Deas GP, Annabelle May CNS, Helen Brewerton CNS, Steven Wanklyn Consultant Pharmacist, Cathy Maylin Community Services Manager. Policy Profile Target Audience: TH Community Team TH Inpatient Unit GP s & DN s Date Issued: October 2014 Review Date October 2016 Individuals/ Groups consulted Medical Lead Community Services; Medical Director; Community Nursing Team; Pharmacy Lead. Approval: Clinical Risk Management Group Date: July 14 Ratification: Clinical Governance Committee (via ) Date: July 14 Document History Version Date Review date Reason for change Version Date EoL symptom control guidelines Pain v1 April14 rev April 15 Page 2 of 10

3 Anticipatory Prescribing ahead of symptoms appearing or worsening: Morphine 5 10 mg subcutaneous infusion to run over 24 hours via a syringe pump Morphine mg subcut 1-hourly PRN 30 Clapham Common North Side London SW4 0RN Tel: End of Life Care symptom control guidance for adult patients: Normal Renal Function PAIN For patients already on an analgesic preparation, including another opioid, seek advice from the Specialist Palliative Care Team at Trinity Hospice Consider: Current medications that are controlling symptoms and could be continued Pre-existing conditions that may influence prescribing (e.g. renal failure egfr< 30 ml/ min) Non-drug measures (see supporting information on page 2) Administer medications according to the current Drug Authorisation Chart Symptoms appear Consider place of care and practical issues Administer medications in one of two ways: Morphine mg subcut immediately Set up a subcutaneous infusion to run over 24 hours via a syringe pump with the above doses clinical situation and PRN dose requirements Symptoms controlled Morphine mg subcut immediately Symptoms after 60 minutes Administer a 2 nd dose of Morphine mg subcut If symptoms Seek adviceand consider: Maintain PRN dosing as above Less frequent dosing will be needed as symptoms become controlled Set up a subcutaneous infusion of Morphine to run over 24 hours via a syringe pump: Morphine 5 10 mg/ 24 hours clinical situation and PRN dose requirements: Morphine mg subcut 1-hourly PRN remain uncontrolled EoL symptom control guidelines Pain v1 April14 rev April 15 Page 3 of 10

4 Supporting information Explain to the patient, their carer(s)/ family what might be causing the symptoms. Consider non-drug interventions that may help relieve pain, for example heat pads or re-positioning if appropriate. Eliminate potentially reversible causes that may be exacerbating symptoms. Consider: - Signs of infection and/ or inflammation. - Signs suggestive of obstruction, constipation (including a PR examination if appropriate) and/ or ascites upon abdominal examination. - Anxiety and/ or confusion. For patients already on an analgesic preparation, including another opioid, seek advice from the Palliative Care Team. Consider using subcutaneous Morphine following the dosing schedule on page 1. Prescribe medication in anticipation of symptoms. A PRN dose should be given immediately symptoms appear, and then when required. In practice, after the first 2-3 PRN doses, it would be uncommon for them to be given so frequently. Consider setting up a subcutaneous infusion of Morphine to run over 24 hours via a syringe pump where: - The patient can no longer swallow oral medications and/ or, - More frequent PRN doses are required When starting a patient on a subcutaneous infusion via a syringe pump who is already on another opioid preparation consider the following for: - Patients currently taking an oral 12-hourly modified release opioid tablet: Start the syringe pump 12 hours after the patient takes their final modified release opioid tablet - Patients currently wearing an opioid patch: Leave the patch on. Start a syringe pump containing opioid at a dose based on the PRN opioid usage over the preceding 24 hours. Remember to adjust the new PRN dose of opioid which should be based on the total Opioid dose being administered over 24 hours (i.e. the patch + the subcut syringe pump doses). Remember: continue to replace the patch when this is due. If symptoms or if you need advice/ support, contact the Palliative Care Team: Resources to improve the safety of opioids in clinical practice are available from the London Opioid Safety and Improvement group. losig@gstt.nhs.uk for more information. EoL symptom control guidelines Pain v1 April14 rev April 15 Page 4 of 10

5 End of Life Care symptom control guidance for adult patients: Normal Renal Function AGITATION AND DISTRESS Consider: Current medications that are controlling symptoms and could be continued Pre-existing conditions that may influence prescribing (e.g. renal failure egfr< 30 ml/ min) Non-drug measures (see supporting information on page 2) Administer medications according to the current Drug Authorisation Chart 30 Clapham Common North Side London SW4 0RN Tel: Anticipatory Prescribing ahead of symptoms appearing or worsening: Midazolam mg subcutaneous infusion to run over 24 hours via a syringe pump Midazolam 2.5 mg subcut 1-hourly PRN Symptoms appear Consider place of care and practical issues Administer medications in one of two ways: Midazolam 2.5 mg subcut immediately Set up a subcutaneous infusion to run over 24 hours via a syringe pump with the above doses clinical situation and PRN dose requirements Symptoms controlled Midazolam 2.5 mg subcut immediately Symptoms after 60 minutes Administer a 2 nd dose of Midazolam 2.5 mg subcut If symptoms Seek adviceand consider: Maintain PRN dosing as above Less frequent dosing will be needed as symptoms become controlled Set up a subcutaneous infusion of Midazolam to run over 24 hours via a syringe pump: Midazolam mg/ 24 hours clinical situation and PRN dose requirements: Midazolam 2.5 mg subcut 1-hourly PRN remain uncontrolled EoL symptom control guidelines Pain v1 April14 rev April 15 Page 5 of 10

6 Supporting information Explain to the patient if possible, the patient s carer(s)/ family what might be causing the symptoms and that it is not likely to distress the patient if they are unconscious. Eliminate potentially reversible causes, in particular pain and discomfort that may be caused by a full bladder or rectum. If it is necessary to consider sedation this should be discussed with the patient, if possible, and their carer(s)/ family. Consider using subcutaneous Midazolam following the dosing schedule on page 1. Prescribe medication in anticipation of symptoms. A PRN dose should be given immediately symptoms appear, and then when required. In practice, after the first 2-3 PRN doses, it would be uncommon for them to be given so frequently. Consider setting up a subcutaneous infusion of Midazolam to run over 24 hours via a syringe pump where: - The patient can no longer swallow oral medications and/ or, - More frequent PRN doses are required If symptoms or if you need advice/ support, contact the Palliative Care Team. EoL symptom control guidelines Pain v1 April14 rev April 15 Page 6 of 10

7 30 Clapham Common North Side London SW4 0RN Tel: End of Life Care symptom control guidance for adult patients: Normal Renal Function NAUSEA AND VOMITING Consider: Current medications that are controlling symptoms and could be continued Pre-existing conditions that may influence prescribing (e.g. renal failure egfr< 30 ml/ min) Non-drug measures (see supporting information on page 2) Administer medications according to the current Drug Authorisation Chart If bowel obstruction is suspected, seek advice from the Palliative Care Team Anticipatory Prescribing ahead of symptoms appearing or worsening: Haloperidol 2.5mg -5 mg subcutaneous infusion to run over 24 hours via a syringe pump Haloperidol 1.5 mg subcut 1-hourly PRN Symptoms appear Consider place of care and practical issues Administer medications in one of two ways: Haloperidol 1.5 mg subcut immediately Set up a subcutaneous infusion to run over 24 hours via a syringe pump with the above doses clinical situation and PRN dose requirements Symptoms controlled Haloperidol 1.5 mg subcut immediately Symptoms after 60 minutes Administer a 2 nd dose of Haloperidol 1.5 mg subcut If symptoms Seek adviceand consider: Maintain PRN dosing as above Less frequent dosing will be needed as symptoms become controlled Set up a subcutaneous infusion of Haloperidol to run over 24 hours via a syringe pump: Haloperidol 2.5 5mg / 24 hours clinical situation and PRN dose requirements: Haloperidol 1.5 mg subcut 1-hourly PRN remain uncontrolled EoL symptom control guidelines Pain v1 April14 rev April 15 Page 7 of 10

8 Supporting information Nausea and vomiting is common in palliative care, with up to 70% of patients being affected in the last week of life. Explain to the patient, their carer(s)/ family what might be causing the symptoms. Eliminate potentially reversible causes that may be exacerbating symptoms. Consider: - Signs of dehydration or infection. - Oral problems, for example dry mouth or thrush. - Signs suggestive of obstruction, constipation (including a PR examination if appropriate) and/ or ascites upon abdominal examination. - Anxiety and/ or confusion. Consider using subcutaneous Haloperidol following the dosing schedule on page 1. Prescribe medication in anticipation of symptoms. A PRN dose should be given immediately symptoms appear, and then when required. In practice, after the first 2-3 PRN doses, it would be uncommon for them to be given so frequently. Consider setting up a subcutaneous infusion of Haloperidol to run over 24 hours via a syringe pump where: - The patient can no longer swallow oral medications and/ or, - More frequent PRN doses are required If symptoms or if you need advice/ support, contact the Palliative Care Team. EoL symptom control guidelines Pain v1 April14 rev April 15 Page 8 of 10

9 End of Life Care symptom control guidance for adult patients: Normal Renal Function RESPIRATORY TRACT SECRETIONS Consider: Current medications that are controlling symptoms and could be continued Pre-existing conditions that may influence prescribing (e.g. renal failure egfr< 30 ml/ min) Non-drug measures (see supporting information on page 2) Administer medications according to the current Drug Authorisation Chart Anticipatory Prescribing ahead of symptoms appearing or worsening: Hyoscine Butylbromide (Buscopan) 20 mg subcut 1-hourly PRN Hyoscine Butylbromide 60 mg subcutaneous infusion to run over 24 hours via a syringe pump 30 Clapham Common North Side London SW4 0RN Tel: Symptoms appear Consider place of care and practical issues Administer medications in one of two ways: Hyoscine Butylbromide 20 mg subcut immediately Set up a subcutaneous infusion to run over 24 hours via a syringe pump with the above doses clinical situation and PRN dose requirements remain uncontrolled Symptoms controlled Hyoscine Butylbromide 20 mg subcut immediately Symptoms after 60 minutes Administer a 2 nd subcut dose of Hyoscine Butylbromide 20 mg If symptoms Seek adviceand consider: Maintain PRN dosing as above Less frequent dosing will be needed as symptoms become controlled Set up a subcutaneous infusion of Hyoscine Butylbromide to run over 24 hours via a syringe pump: Hyoscine Butylbromide (Buscopan) 60 mg / 24 hours clinical situation and PRN dose requirements: Hyoscine Butylbromide 20 mg subcut 1-hourly PRN remain uncontrolled EoL symptom control guidelines Pain v1 April14 rev April 15 Page 9 of 10

10 Supporting information This symptom is due to aspirated oropharyngeal secretions and retained bronchial secretions, although in some patients there maybe underlying infection. Explain to the patient s carer(s)/ family what is causing the secretions/ noise, and that the noise itself is not likely to distress the patient if they are unconscious. Repositioning the patient to one side may stop secretions pooling in the pharynx, reducing the noise. Anticholinergic drugs have no effect on secretions that are already present. If infection is present Anticholinergics may make secretions more tenacious and can therefore be unhelpful. Suctioning may not be appropriate. Drug therapy is effective in approximately 50% of patients. Consider using subcutaneous Hyoscine Butylbromide (Buscopan) following the dosing schedule on page 1. Prescribe medication in anticipation of symptoms. A PRN dose should be given immediately symptoms appear, and then when required. In practice, after the first 2-3 PRN doses, it would be uncommon for them to be given so frequently. Consider setting up a subcutaneous infusion of Hyoscine Butylbromide to run over 24 hours via a syringe pump where: - The patient can no longer swallow oral medications and/ or, - More frequent PRN doses are required If symptoms or if you need advice/ support, contact the Palliative Care Team. EoL symptom control guidelines Pain v1 April14 rev April 15 Page 10 of 10

Care in the Last Days of Life

Care in the Last Days of Life Introduction This guideline is an aid to clinical decision making and good practice in person-centred care for patients who are deteriorating and at risk of dying. The patient